Download Intro_EBM

Internal Medicine Residency
Evidence-Based Practice Intro
& Curriculum
Integrating Evidence-Based Medicine
Into Clinical Practice
"The extent to which beliefs
are based on evidence is very
much less than believers
suppose.“
Sceptical Essays, Bertrand Russell, 1928
Background
• The ACGME and AAMC have called for intro of clinical
epidemiology, biostatistics, critical appraisal, and medical
informatics in medical school and GME curricula
• Traditional method: Journal Club
•95% of programs reporting an active Journal Club1
• Emerging Method: dedicated EBM curriculum
•Includes Journal Club
•only 37% of programs report having such courses2
1Sidorov,
2Green,
J. Archives of Internal Medicine, 1995; 155:1193-7.
M. Journal of General Internal Medicine, 2000; 15:129-33
Evidence-Based Practice Curriculum
• Goals and Objectives
– Improve residents’ ability to integrate
clinical evidence into medical practice.
– Improve EBM skills
• Ask well-built clinical questions
• Perform effective (efficient) literature searches
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Utilize the NLM, other databases
Use “best-evidence” resources, primary literature
Learn basic critical appraisal skills
• Apply to patients
Evidence-Based Practice Curriculum
• Goals and Objectives
– Reduce barriers to accessing primary literature
– Foster a sense of independence
• Improved EBM self-efficacy
• Enhance pattern of lifelong learning
– Promote self-efficacy in and professional ethic
of practice-based learning and systems-based
practice improvement
Evidence-Based Practice:
Curriculum Elements I - Content
EBM Core Topics for Conferences/Rounds
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Intro to EBP, Asking clinical questions
Finding the Evidence
Articles about Therapy
Articles about Diagnosis
Articles about Harm/Etiology
Articles about Prognosis
Overviews/Meta-analysis
Basic Biostatistics & Epidemiology
Likelihood Ratios, Medical decision making
Evidence-Based Practice:
Curriculum Elements II - Avenues
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Monthly Journal Club
M & M/ quality improvement conference
Ward Evidence-based Medicine Rounds
Annual Intern Project (more later)
Resident Practice Improvement Modules
(PIM’s) through ABIM (more later)
– Morning Report, Attending Rounds,
Preclinical conferences
Evidence-Based Practice Curriculum
• EBP Attending Rounds
– Goals:
• Consolidate K/S/A taught in the core curriculum
• Expand our knowledge base
– Monthly structure
• 4th Week  Tue, Wed, Thu @ 0815-0845
• Teams prepare discussion
• Present/discuss with facilitator, staff, and chief
• Brief summary placed on web and in each
intern/resident’s training portfolios – due by
Thursday COB that week
Evidence-Based Practice Rounds
Each team prepares the following presentation:
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A brief H&P and clinical question
–
Medical student – 2 min
Search process
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Intern – 3 min
Presentation of the best evidence
–
Intern – 5 min
Critical Appraisal using McMaster criteria
–
Resident - 10 minutes
Group discussion: How can the information be
applied?
Evidence-Based Practice Basics:
Asking the Right Questions
“The most important thing is to
never stop questioning”
-Albert Einstein
What is EBM?
“the conscientious, explicit and judicious
use of current best evidence in making
decisions about the care of the
individual patient. It means integrating
individual clinical expertise with the
best available external clinical evidence
from systematic research."
-Sackett D, 1996
What is EBM?
• Medical decisions based on:
– best research evidence
– clinical expertise
– patient values
• Useful framework:
– good patient care
– effective medical education
What EBM is not.
• Rigid format that removes clinical
judgment
What does it mean to “Practice EBM”?
(Recognize the 4 A’s)
1) Recognize: need for information
2) Ask: answerable clinical question
3) Acquire: search for “best evidence”
4) Assess: critical appraisal (validity, impact)
5) Apply: integrate with your patient
 Own clinical expertise
 Patient’s unique biology,
values, and circumstances
Case – Obscure GI Bleed
Your patient: 64 yo man admitted to your service
after presenting to the ED with weakness.
In the ED: heme (+) stools and microcytic anemia
Further eval:
-verified Fe deficiency, but colo/EGD (-)
-no signs of hemolysis or heme pathology
You transfuse and discharge him, but he returns
one month later, with the same thing.
What kind of information can help you
with the management of this patient?
Step 1: Recognize need for info
• Learning entry point is curiosity…
need to know
• Doctors under-estimate our need for info
– Up to 5 times per inpatient encounter
– 2 out of 3 outpatient visits
Work of getting information
+
Limited Time
Information
needs not met
Getting knowledge into practice…
Acquisition versus Application
• Replicative
– Read/remember
– Implicitly accept/follow
• Appraisal-based
– Involves all five steps of EBM
– Time consuming…easier with practice!
– Use for: problems dealt with most often
• E.g. Morning report, Journal Club, EBM rounds
Getting knowledge into practice…
Acquisition versus Application
• EBM Review-based
– Skips lengthy critical appraisal step
– Only search pre-appraised resources
• Explicit criteria for evidence selection
• Rigorous evaluation for validity
– Examples: Cochrane Database, ACP Journal
Club, Clinical Evidence, UpToDate?
– Use for: day-to-day questions in busy
practice/ward
Step 2: Convert Info Need into…
Answerable Clinical Question
• Good Clinical Questions:
– Begin with patient issue
– Clarify particular informational needs
– Make knowledge acquisition timely
…It’s unlikely that management conference this week
will coincidentally be about your patient
– Suggest high-yield search strategies
– Entry point for evidence-based learning
Different Types of Questions
Case: 47 year old woman with systemic lupus on
prednisone presents with two days of nausea and
abdominal discomfort and one day of vomiting,
occasionally with coffee ground emesis.
Supine BP 120/65, pulse 65;
Standing BP 112/55, pulse is 71.
Labs: Hct 32, creatinine 2.3 (1.2 last March), urine
sediment has some red cells and granular casts.
What questions would you ask about this
patient?
Different Types of Questions
Background Questions
– Ask for general knowledge about disorder
– 2 essential components
1. A question root (5 W’s) with a verb
2. A disorder or aspect of a disorder
– Examples:
• How do you work up a GI bleeder?
• What is relationship between H. Pylori and steroids?
• What are the renal manifestations of lupus?
• Why are interns so tired?
Different Types of Questions
Foreground Questions
– Asks for specific knowledge
– Usually refer to patients
– Three (or four) components
• Patient (or problem) of interest
• Intervention of interest– “an exposure”
• Comparison intervention (if relevant)
• Outcome of clinical interest
Different Types of Questions
Foreground Question Examples:
– For patients on chronic steroids with acute GI bleed
due to PUD, does H. Pylori Rx reduce rebleeding?
– For patients with lupus and suspected acute lupus
nephritis, what is the prognostic value of renal
biopsy?
Types of Questions
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Clinical Findings: how to gather & interpret findings from the H&P
Etiology: how to identify causes for disease
DDx: what are they, ranked by likelihood, seriousness, and treatability
Diagnostic Tests: confirm/exclude a dx: look at test characteristics
(sensitivity, specificity, accuracy, PPV/NPV, safety, expense, etc.)
• Prognosis: estimate likely clinical course and anticipate likely
complications of disease.
• Therapy: select treatments that do more good than harm and worth
the effort and cost of using them
• Prevention: reduce chance of disease by identifying and modifying
risk factors and how to screen for disease
Practice Asking Questions…
• 47 y/o man with sarcoidosis has recently
been diagnosed with HIV
• “Doctor, how will my HIV affect my
sarcoidosis?”
What’s the Purpose?
• In patients with sarcoidosis, does HIV lessen or
•
worsen their disease severity?
A question of…
A)
B)
C)
D)
E)
Diagnosis
Prognosis
Etiology
Therapy
Prevention
What’s the Purpose?
• In patients with sarcoidosis, does HIV lessen or
•
worsen their disease severity?
A question of…
A) Diagnosis
B) Prognosis
C) Etiology
D) Therapy
E) Prevention
The Elements
P - The patient/population OR problem
being addressed
I - The “intervention” or question
C - A comparison (when relevant)
O - The outcome or outcomes of interest
The Elements
P - The patient/population OR problem
being addressed
Sarcoidosis
I - The “intervention” or question
C - A comparison (when relevant)
O - The outcome or outcomes of interest
The Elements
P - The patient/population OR problem
being addressed
Sarcoidosis
I - The “intervention” or question
HIV/AIDS
C - A comparison (when relevant)
O - The outcome or outcomes of interest
The Elements
P - The patient/population OR problem
being addressed
Sarcoidosis
I - The “intervention” or question
HIV/AIDS
C - A comparison (when relevant)
no HIV/AIDS
O - The outcome or outcomes of interest
The Elements
P - The patient/population OR problem
being addressed
Sarcoidosis
I - The “intervention” or question
HIV/AIDS
C - A comparison (when relevant)
no HIV/AIDS
O - The outcome or outcomes of interest
Severity
Type of Question?
Background or Foreground?
The Search
1. exp SARCOIDOSIS, PULMONARY/
or exp SARCOIDOSIS/ or sarcoidosis.mp.
15526
2. (HIV or human immunodeficiency virus).mp.
mp=title, original title, abstract, name
of substance, mesh subject heading]
3. (AIDS or autoimmune deficiency syndrome).mp.
[mp=title, original title, abstract, name of
substance, mesh subject heading]
4. (prognosis or symptoms or survival or mortality
or quality of life or outcome).mp. [mp=title, original title,
abstract, name of substance, mesh subject heading]
5. 2 or 3
171810
6. 1 and 5
7. 4 and 6
10. from 7 keep 1-2, 4, 14-15, 17
126887
78196
911606
140
22
6
The Results
1.
Pulmonary symptoms and lymphadenopathy
in a human immunodeficiency virus-infected woman. [Case Reports. Journal
Article] Archives of Pathology & Laboratory Medicine. 127(1):111-2, 2003 Jan.
Hill KA. Till M. Laskin WB. Pathologic quiz case:
UI: 12562277
2.
Newly diagnosed pulmonary sarcoidosis in
HIV-infected patients. [Journal Article] Radiology. 218(1):242-6, 2001 Jan.
Haramati LB. Lee G. Singh A. Molina PL. White CS.
UI: 11152809
3.
Coexistent sarcoidosis and HIV
infection. A comparison of bronchoalveolar and peripheral blood lymphocytes.[see
comment]. [Case Reports. Journal Article] Chest. 102(6):1899-901, 1992 Dec.
Newman TG. Minkowitz S. Hanna A. Sikand R. Fuleihan F.
UI: 1446516
4.
Sarcoidosis complicated by HIV infection:
three case reports and a review of the literature. [Review] [25 refs] [Case Reports.
Journal Article. Review. Review of Reported Cases] American Review of Respiratory Disease.
Lowery WS. Whitlock WL. Dietrich RA. Fine JM.
142(4):887-9, 1990 Oct.
UI: 2221596
5.
Gowda KS. Mayers I. Shafran SD. Concomitant
sarcoidosis and HIV infection. [Case
Reports. Journal Article] CMAJ Canadian Medical Association Journal. 142(2):136-7, 1990 Jan 15.
6.
UI: 2295031
Foulon G. Wislez M. Naccache JM. Blanc FX. Rabbat A. Israel-Biet D. Valeyre D. Mayaud C. Cadranel J.
Sarcoidosis in HIV-infected patients in the era of highly active antiretroviral
therapy. [Journal Article] Clinical Infectious Diseases. 38(3):418-25, 2004 Feb 1.
UI: 14727215
The Results
1.
Pulmonary symptoms and lymphadenopathy
in a human immunodeficiency virus-infected woman. [Case Reports. Journal
Article] Archives of Pathology & Laboratory Medicine. 127(1):111-2, 2003 Jan.
Hill KA. Till M. Laskin WB. Pathologic quiz case:
UI: 12562277
2.
Newly diagnosed pulmonary sarcoidosis in
HIV-infected patients. [Journal Article] Radiology. 218(1):242-6, 2001 Jan.
Haramati LB. Lee G. Singh A. Molina PL. White CS.
UI: 11152809
3.
Coexistent sarcoidosis and HIV
infection. A comparison of bronchoalveolar and peripheral blood lymphocytes.[see
comment]. [Case Reports. Journal Article] Chest. 102(6):1899-901, 1992 Dec.
Newman TG. Minkowitz S. Hanna A. Sikand R. Fuleihan F.
UI: 1446516
4.
Sarcoidosis complicated by HIV infection:
three case reports and a review of the literature. [Review] [25 refs] [Case Reports.
Journal Article. Review. Review of Reported Cases] American Review of Respiratory Disease.
Lowery WS. Whitlock WL. Dietrich RA. Fine JM.
142(4):887-9, 1990 Oct.
UI: 2221596
5.
Gowda KS. Mayers I. Shafran SD. Concomitant
sarcoidosis and HIV infection. [Case
Reports. Journal Article] CMAJ Canadian Medical Association Journal. 142(2):136-7, 1990 Jan 15.
6.
UI: 2295031
Foulon G. Wislez M. Naccache JM. Blanc FX. Rabbat A. Israel-Biet D. Valeyre D. Mayaud C. Cadranel J.
Sarcoidosis in HIV-infected patients in the era of highly active antiretroviral
therapy. [Journal Article] Clinical Infectious Diseases. 38(3):418-25, 2004 Feb 1.
UI: 14727215
Remember “P-I-C-O”
P – Patient
I – Intervention
C – Comparison
O – Outcome
EBM is not an end in itself…
“Whoever undertakes to set
himself up as judge in the field
of truth and knowledge is
shipwrecked by the laughter of
the Gods.”
-Albert Einstein